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Comprehensive history taking

A comprehensive history taking is a way to perform a History-taking from a patient. The features of it is that the questioner have a complete set of questions to ask, in contrast to iterative hypothesis testing, where the questioner adapt his/her questions to the circumstances. Therefore, comprehensive history taking is mostly performed by Medicine students, who aren't yet as experienced that they can improvize. Afterwards, the Medicine student can report all the answers to a physician, who can put the right w:diagnosis.

Performance

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This is an example of how a comprehensive history taking could be performed.

Presentation

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  • Greet the patient, present yourself and the purpose of the meeting.
  • Listen Start with open-ended questions and let the patient tell freely.
  • Specify with restricted questions.

w:chief complaint or presenting illness

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  • Why do you seek health care today? New trouble or worsening of an earlier one?
  • w:Symtoms
  • Localization. Where? Does it change position?
  • Debut
  • Duration
  • Worsening factors. Body position? Exercise? Food intake?
  • Alleviating factors. Is there anything that makes the symtoms better?
  • Restriction of life. Worse sleep? Apetite?

Ongoing illnesses

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E.g. w:diabetes, w:rheumatism, hypertension

Past medical history

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Includes illnesses that are already treated.

  • major illnesses,
  • any previous surgery/operations

It's important to get to know:

  • What illness?
  • when?
  • where it was treated
  • how it was treated

Medication

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What kind of medicines is the patient taking? It also includes:

  • Medication taken regularily as well as when necessary
  • Over-the-counter medications
  • contraceptive pills

It's important to know:

  • Form (pills, injections)
  • Name
  • Strength (mg/pill)
  • Doses/day

Heredity

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Has anybody in the family had similar problems?

Social

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  • Profession. Environment? Stress? Tasks? Unemployed?
  • Family. Live alone or with husband/wife? Children? How many? Do they live nearby?
  • Residence. House? Flat? Which floor? Is there an elevator?
  • ADL Independent or home help? Get about with stick/walker.
  • w:Exercise and w:nutrition
  • w:Tobacco smoking. How many cigarettes/day? Smoked earlier?
  • w:Alcoholic beverages. How many centilitres of beer, wine and spirits.

Gynecologic

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This is of interest in fertile women or women after w:menopause.

Abuse

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  • Ongoing drugs?
  • Debut?
  • Treatment?
  • Complications?
  • Withdrawal-symptoms?
  • Social contacts?
  • Contact with addiction health care?

Allergies

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To medications? Food? What is the reaction? Rashes? w:Dyspnea?

Organ-specific questions

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In addition to general questions, the Medicine student could also have an arsenal of organ-specific questions, in order to put the right w:differential diagnosis.

w:Gastrointestinal problems

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  • How long time?
  • Consistency of faeces?
  • Number of defecations/day?
  • Nocturnal problems?
  • Blood content?
  • Problems after meal?
  • Pain?
  • Weight loss?

Upper abdominal problem

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Liver disease

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Chest pain

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  • How long time?
  • Have the problems changed?
  • Duration of an attack?
  • What triggers an attack?
  • How does the patient break an attack?
  • Localization?
  • Characteristics of the pain?
  • Radiation?

Dyspnea

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  • How long time?
  • Is it constant or coming and going?
  • Smoking?
  • Cough? Blood present?
  • Worsening factors
  • Alleviating factors

Joint problems

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  • How long time?
  • Which joints?
  • w:Morning stiffness?
  • Has the patient had any disease the month before the visit?
  • Is the pain worse in rest or in motion?
  • Symtoms from other organs?

Weight loss/fatigue

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  • How long time?
  • Was there a triggering cause?
  • Worsening factors?
  • Does sleep alleviate?
  • Variations over the day?
  • Is the appetite normal?
  • How large weight loss?
  • Colour and consistency of faeces?
  • Amount and colour of urine?

Unconsciousness

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(A relative gives the medical history)

  • When did the patient become unconscious?
  • Was there a sudden or gradual debut?
  • Urine/faeces-micturition?
  • Cramps?
  • What was the colour of the skin?
  • Medications?
  • Psychiatric symtoms?
  • Suicidal thoughts?
  • Abuse?
  • w:Physical trauma?
  • Vomiting?

Finally, Sum up what the patient has said to be sure you've got it right.

References

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  • Kompendium för Status och anamnes, Anders Albinsson (translated from Swedish)
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